A nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of the following findings should the nurse report to the provider?

A. Inform the client that an advance directive discontinues further care.This statement is incorrect. An advance directive does not discontinue further care but outlines the client's preferences for medical treatment if they become unable to communicate their wishes.

B. Initiate a power of attorney for health care documents.This is not the nurse's responsibility. Initiating a power of attorney for health care documents typically involves legal consultation, and the client should be referred to appropriate resources.

C. Document that the provider discussed do-not-resuscitate status with the client.This is correct. The nurse should document that the provider has discussed DNR (Do Not Resuscitate) status with the client, ensuring that the discussion and decision are clearly recorded in the medical record.

D. Provide the client with written information about advance directives.This is correct. The nurse is responsible for providing the client with written information about advance directives, ensuring the client understands their rights and options.

E. Communicate advance directives status via the medical record and shift report.This is correct. The nurse must ensure that the client's advance directive status is clearly communicated in the medical record and during shift reports to ensure continuity of care.

F. Instruct the client that an advance directive is a legal document and must be honored by care providers.This is correct. The nurse should inform the client that an advance directive is a legal document that healthcare providers are required to honor, according to the client's wishes.

The correct answer is Choice A.

Choice A rationale: By stating expectations for the client’s behavior, the nurse is addressing the immediate situation and setting clear boundaries.This intervention allows the nurse to assertively communicate with the client, reminding them of appropriate behavior and potentially diffusing the situation1.

Choice B rationale: Requesting security personnel to restrain the client should be a last resort, used only when the client poses a significant risk to themselves or others and all other de-escalation techniques have failed. Restraint can be traumatic and has potential physical and psychological risks.

Choice C rationale: Placing the client in seclusion is another measure that should be used sparingly and only when necessary for the safety of the client or others. It’s important to try less restrictive measures first, such as verbal de-escalation techniques or offering a quiet, private space where the client can regain control.

Choice D rationale: Debriefing staff members about the conflict is an important step, but it should not be the first action. The immediate priority is to ensure the safety of all clients and to de-escalate the situation.